Helping children - or controlling them?
Alan Krohnke got too tough to control. Hooked on drugs and alcohol, stealing from his parents, he made life so difficult that his exasperated family finally kicked him out of the house. For six months the 17-year-old saw his parents only twice. Then in August, the Minneapolis police picked him up for stealing a stereo out of a nearby house.
Fifteen years ago, a teen-ager like Alan might have been locked up in juvenile detention or shipped off to a hard-nosed relative. But on this night he was taken to a private psychiatric hospital in Minneapolis. For three days he recuperated in the locked detoxification facility of Fairview Deaconess Center. Then, handcuffed, he was transferred with his parents' permission to the hospital's locked evaluation unit.
The number of children placed with the `new guardians' is not overwhelming. The most restrictive institutions - private psychiatric hospitals and residential treatment centers - admit an estimated 100,000 youths each year, less than 1 percent of the US juvenile population. What disturbs many is the dramatic growth. Since 1970, juvenile admissions to private psychiatric hospitals are up sixfold; for residential treatment centers, figures show at least a twofold increase.
Critics charge that the new guardians are dreaming up psychiatric disorders so they can treat more children. The facilities claim they are responding to the needs of a much sicker society. Either way, the phenomenon is disturbing. With few industrywide standards and even less agreement among professionals on what is appropriate treatment, the new guardians sometimes help children and usually make money in the process. Even child professionals worry.
Need vs. supply
``There's been such an enormous expansion of adolescent [beds] over the last 10 years, primarily in the private sector, that one has a real concern as to whether all of these beds are needed,'' says Jerry Wiener, president-elect of the American Academy of Child and Adolescent Psychiatry. ``I don't think the real need has kept up with the supply.''
When Randa Steele's 14-year-old son became uncontrollable one night after drinking, his parents checked him into HCA Truckee Meadows Hospital in Reno, Nev. For eight months of treatment, their son racked up $75,000 in bills, and he seemed to get worse. According to the Steeles, former Los Angeles police officers, their son grew increasingly incoherent because of drugs he was given. Mrs. Steele recalls the day she pulled her son out: ``His posture was very stooped, with his arms sticking out. He wasn't able to put his hands in his pockets.''
When a well-known San Francisco psychiatric hospital took the boy, it reduced, then eliminated, his medication and released him after seven weeks. Since Truckee Meadows had exhausted the family's insurance benefits, the Steeles picked up the $14,700 tab.
So far, much of the controversy surrounding the new guardians has focused on admissions. Television cameras have caught some facilities accepting children on the flimsiest evidence. In El Paso, Texas, an 18-year-old was tricked by his mother into entering a parent-sponsored drug-treatment program and held there for two months until a lawyer and the police got him released. In Los Angeles, a woman is suing a private psychiatric hospital because when she was 17, she was admitted there by her parents, who disapproved of her 30-year-old boyfriend.
``The irony of it is that if you're in prison, your civil liberties are going to be much more closely guarded,'' says Louise Monaco, the young woman's lawyer.
Many child-advocates argue that teen-age rights are being abused, but the law is often murky. The US Supreme Court ruled in 1979 that parents have the right to institutionalize a minor as long as the admitting physician agrees. California law allows children 14 years and older a pre-admission hearing to state hospitals but is silent about the expanding number of private-sector institutions.
While such questionable admissions do occur, child professionals say, larger controversies involve the quality of care and length of stay with the new guardians.
``It's not the intake process that's at fault often,'' says Dr. Ira S. Lourie at the National Institute of Mental Health. ``It's the discharge process.''
Fairview Deaconess, where Alan Krohnke was sent, is a brick hospital in a Minneapolis neighborhood. Alan's parents say they are grateful for the hospital. Their son is now a drug-free sophomore at Lawrence University in Appleton, Wis. Alan is ambivalent. He liked the outpatient treatment but found his two weeks of inpatient care too manipulative.
``Any little slip-ups, they really chastised you for it,'' he says. ``It was always: `Break down and confess.'''
When he told one counselor that she was contradicting his psychiatrist, he was confined to his room for 24 hours. Alan says another counselor deliberately misled him on an assignment, so his psychiatrist could create a crisis the next day, yelling and threatening that Alan would have to stay an extra week. ``The threats were never serious,'' he recalls. ``I got out the next day. [But] I had real problems with self-esteem after the chemical-dependency treatment.''
What constitutes quality care?
Facilities around the country often confront their addicted or troubled patients when they deny they have a problem. But there are no widely accepted standards to determine how far counselors can go - or, for that matter, what really constitutes quality care, child professionals agree. The result is that one professional's ``treatment'' is another's ``unjustified punishment.''
When one of his friends committed suicide two years ago, Peter B. of St. Paul became very depressed and very high on pot, and he started talking about committing suicide. Already in Deaconess's aftercare program for heavy drug use, he was placed, not in its crisis unit, but in its locked detoxification unit, even though Peter was by this time sober again.
Thomas Collins, executive director of adolescent chemical-dependency services at Deaconess, calls the treatment an experiment to ``snap [patients] back in time and say, `Boy, do I really want to live like this again?'... We thought that had clinical integrity and met all our other goals.''
When the county investigated, however, it found that Peter and another sober child were admitted to detoxification merely because no beds were available in the crisis unit. Of four other suspect cases brought to its attention, the county found three where sober children were admitted to the detoxification unit as punishment, either because of their attitude or because they had previously used drugs. The county called these examples undesirable. The facility said such practices had been discontinued.
When Jeff Mitchell, an assistant professor of child psychology at the University of Washington, visited Truckee Meadows in Reno, he says he found several bizarre treatments used by Stuart Wyckoff, the facility's adolescent medical director. One young teen-ager was strapped to a wheelchair for weeks, and others are required to wear name tags saying such things as, ``If I'm being negative, please point it out to me,'' or ``Help me correct my aggressive attitude.''
Other techniques are also used at the facility, Dr. Wyckoff says. For example, children can be ``restricted to unit,'' which means that for up to three or four days they must sit at the head-nurse station and do their schoolwork. Other children are not allowed to talk with them. If they do, they can be ``timed out,'' ordered to sit quietly for 30 minutes and then spend another 30 minutes writing an assignment about the situation.
Perhaps two or three times a year, the staff and psychiatrist declare a unit shutdown, or ``discovery program.'' It usually occurs when there are many new patients on the unit, Wyckoff explains, when ``you tend to have a hostile place where most of the kids form a negative attitude against the staff.'' Regular procedures are preempted and the children meet in various-size groups, which can last up to 10 hours a day.
Some of the techniques at Truckee Meadows are more severe than those used at other facilities around the country, but the philosophy of institutional control is common among the new guardians. Some critics are repulsed by it. ``It's a mushrooming national scandal,'' says Ira Schwartz, director of the youth policy center at the University of Minnesota.
Teaching what is `good'
Many child professionals see it as therapeutic.
``We tell [the children] when they come in: `You can't do what you want to do. You have to do what's good for you now,''' says Clifford L. Corman, medical director of adolescent psychiatry at Golden Valley Health Center outside Minneapolis. ``And they say: `Well, how do you know what's good for me?' I say: `I don't know for sure, but there are certain guidelines that I'm going to follow and you're going to have to go along with it whether you like it or not.' And they call me a bunch of names and that's the way it starts. ... I'm teaching what is good for them. And if it's good for them, why shouldn't they like it by the time they leave?''
Some do. By the 10th grade, Howie Roston was so strung out on drugs and alcohol that he dropped out of school. His mother, Eileen, recalls his bashing in doors at home. ``The thing that bothered me the most was that I had no control.'' Since treatment at Golden Valley, Howie has stayed straight for a year and a half. ``Every day I'm sober, it's a breakthrough,'' he says.
Brian H., a 10th-grader with an earnest face, wasn't helped at Golden Valley. Counselors challenged him about his drinking. ``I told the truth. And they said I was lying,'' he recalls. The staff challenged him about other behavior.
Golden Valley apparently felt strongly about Brian, because his mother says she was threatened with a lawsuit when she decided to pull him out of the center - one of several instances the Monitor found of the new guardians trying to control parents as well as children.
The debate over the new guardians has no middle ground. Says Alan Krohnke, the now-straight teen-ager, ``If the ends justify the means, then yes,'' he says, the controlling techniques are OK. ``But I think the means are questionable.''
Next: Money fuels program growth